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###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___: Left heart cath
###RESPONSE: Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest Pain {Chest pain}, Left heart cath {Catheterization of left heart} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
The majority of the history of obtained through the patient's
son and chart review as the patient does not speak ___.
Mr. ___ is a ___ year old gentleman with history of CAD s/p
3v CABG in ___, HTN, HLD, DM type II who presents with chest
pain.
Substernal chest pain, ___, per patient's son similar to the
pain that lead to his CABG started last night associated with
palpitations, diaporesis and dyspnea. The severe pain lasted ___
hrs. It improved overnight to ___. He was having difficulty
sleeping last night because of the pain. He didn't tell anyone
until his son came back home from work today. Today he tried to
go down some stairs in his 2 story house and became very
dyspenic and felt palpitations.
His son took him to ___ where initial vitals were
97.3, 76, ___. Significant labs include WBC 13.3.
BUN/Cr ___. Trop I 0.160 (ref range ___, BNP 58. CXR
there without acute processes. EKG shows LVH but otherwise no
evidence of ischemia. He was given ASA 325mg, Nitro SL x 2 and
Nitro paste with resolution of symptoms and correction of
hypertension. Vital sign prior to transfer to ___ 134/86 64 16
100%RA.
In the ED intial vitals were: 96.9 70 150/78 18 99% 0
Labs: 11.3 WBC with 12.7% eos. BUN/Cr ___.
Patient was given: nitro SL x2 with and nitro paste at the OSH
and morphine 5mg IV once in the ED. Trop <0.01.
Vitals on transfer: 98 72 120/72 16 97% RA
On the floor patient currently without chest pain.
###RESPONSE: does not speak {Does not speak}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, HTN {Hypertensive disorder, systemic arterial}, HLD {Hyperlipidemia}, DM type II {Diabetes mellitus type 2}, chest
pain {Chest pain}, Substernal chest pain {Retrosternal pain}, pain {Pain}, CABG {Coronary artery bypass grafting}, palpitations {Palpitations}, diaporesis {Excessive sweating}, dyspnea {Dyspnea}, severe pain {Severe pain}, improved {Patient's condition improved}, difficulty
sleeping {Difficulty sleeping}, pain {Pain}, dyspenic {Dyspnea}, palpitations {Palpitations}, labs {Laboratory test}, WBC {White blood cell count}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, Trop I {Troponin I measurement}, BNP {Brain natriuretic peptide measurement}, CXR {Plain chest X-ray}, EKG {Electrocardiographic procedure}, LVH {Left ventricular hypertrophy}, no
evidence of ischemia {Electrocardiogram: no myocardial ischemia}, ASA {Administration of aspirin}, resolution {Problem resolved}, hypertension {Hypertensive disorder, systemic arterial}, Vital sign {Vital signs finding}, vitals {Vital signs finding}, Labs {Laboratory test}, WBC {White blood cell count}, BUN/Cr {Blood urea nitrogen/creatinine ratio}, Trop {Troponin measurement}, Vitals {Vital signs finding}, chest pain {Chest pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: 3v CABG in ___. LIMA graft to the LAD and vein grafts
to a circumflex marginal and the distal right coronary artery.
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
CAD - 3 vessel disease s/p CABG
HTN
DM type II
HLD
___ disease
Macroscopic hematuria
Proteinuria
cataracts s/p removal of in ___ c/b enucleated eye
urinary incontinence
###RESPONSE: CARDIAC RISK FACTORS {Assessment for risk of cardiovascular disease}, Diabetes {Diabetes mellitus}, Dyslipidemia {Dyslipidemia}, Hypertension {Hypertensive disorder, systemic arterial}, CABG {Coronary artery bypass grafting}, 3v CABG {Coronary artery bypass grafts x 3}, LIMA graft {Internal mammary-coronary artery bypass graft}, LAD {Structure of anterior descending branch of left coronary artery}, vein grafts {Venous graft}, circumflex marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, distal right coronary artery {Structure of distal portion of right coronary artery}, PERCUTANEOUS CORONARY INTERVENTIONS {Percutaneous coronary intervention}, PACING {Cardiac pacing}, ICD {Automatic implantable cardiac defibrillator in situ}, CAD {Coronary arteriosclerosis}, 3 vessel disease {Triple vessel disease of the heart}, CABG {Coronary artery bypass grafting}, HTN {Hypertensive disorder, systemic arterial}, DM type II {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, Macroscopic hematuria {Frank hematuria}, Proteinuria {Proteinuria}, cataracts {Cataract}, urinary incontinence {Urinary incontinence} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Father with ?MI at unknown age. Otherwise no known history of
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
###RESPONSE: MI {Myocardial infarction}, arrhythmia {Cardiac arrhythmia}, cardiomyopathies {Cardiomyopathy}, sudden cardiac death {Sudden cardiac death} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.8 77 176/91 20 100%RA
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e.
###RESPONSE: PHYSICAL EXAMINATION {Physical examination procedure}, VS {Vital signs finding}, RA {Breathing room air}, GENERAL {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were
pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthelasma {Xanthelasma}, NECK {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CARDIAC {Cardiovascular physical examination}, PMI {Finding of apex beat}, intercostal space {Structure of intercostal space}, midclavicular
line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Precordial heave}, No S3 {Third heart sound, S>3<, inaudible}, S4 {Fourth heart sound, S>4<, inaudible}, LUNGS {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, ABDOMEN {Examination of abdomen}, Soft {Abdomen soft}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominal bruits {Abdominal bruit}, EXTREMITIES {Examination of limb} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
Admission Labs
___ 12:15AM BLOOD WBC-11.3* RBC-4.98 Hgb-13.8* Hct-41.3
MCV-83 MCH-27.8 MCHC-33.5 RDW-14.6 Plt ___
___ 12:15AM BLOOD Neuts-64.1 ___ Monos-3.6
Eos-12.7* Baso-0.7
___ 12:15AM BLOOD ___ PTT-38.8* ___
___ 12:15AM BLOOD Glucose-146* UreaN-27* Creat-1.4* Na-138
K-5.1 Cl-105 HCO3-22 AnGap-16
___ 12:15AM BLOOD CK(CPK)-98
___ 12:15AM BLOOD CK-MB-5
___ 12:15AM BLOOD cTropnT-0.01
___ 06:00AM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.3
Discharge LAbs:
Pertinent
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Plt {Platelet count}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Baso {Basophil count}, PTT {Partial thromboplastin time, activated}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, cTropnT {Troponin T cardiac measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Studies:
CT Abd/Pelvis ___
IMPRESSION:
1. Small retroperitoneal hematoma with hemorrhage extending into
a right inguinal hernia sac and alongside the right spermatic
cord.
2. Small hiatal hernia.
3. Calcifications within the pancreas, likely sequela of chronic
pancreatitis.
Echo ___:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular size and global systolic
function. Mild to moderate tricuspid regurgitation.
Compared with the prior study (images reviewed) of ___,
the basal inferior wall has normal function on the current
study.
L Heart Cath:
Report pending, please see finalized report when available
###RESPONSE: CT Abd/Pelvis {Computed tomography of abdomen and pelvis}, retroperitoneal hematoma {Retroperitoneal hematoma}, hemorrhage {Hemorrhage}, right inguinal hernia {Right inguinal hernia}, sac {Hernia sac}, right spermatic
cord {Structure of right spermatic cord}, hiatal hernia {Hiatal hernia}, Calcifications {Pathologic calcification, calcified structure}, pancreas {Pancreatic structure}, chronic
pancreatitis {Chronic pancreatitis}, left atrium {Left atrial structure}, normal in size {Normal size}, right atrial {Right atrial structure}, mild symmetric left ventricular
hypertrophy {Mild left ventricular hypertrophy}, normal cavity size {Normal size}, regional/global systolic
function {Normal left ventricular systolic function and wall motion}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aorta at the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {Normal size}, aortic valve leaflets {Structure of cardiac valve leaflet}, structurally normal {Aortic valve normal}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve
leaflets are mildly thickened {Thickened mitral leaflet}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, pulmonary artery systolic
hypertension {Pulmonary hypertensive arterial disease}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, size {Normal size}, systolic
function {Normal left ventricular systolic function and wall motion}, Mild {Mild tricuspid valve regurgitation}, moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, inferior wall {Structure of myocardium of diaphragmatic region}, normal function {Normal cardiac function}, L Heart Cath {Catheterization of left heart} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ w/ hx of CAD s/p CABG in ___ transferred from OSH for chest
pain and shortness of breath.
Active Issues:
#Chest pain: Negative trops but found to have V5-V6 depression
on subsequent EKG, concerning for new ischemia. He was diuresed
given his shortness of breath with improvement and taken to cath
lab where angiogram showed occluded SVG to OM, appearing chronic
in nature. Medically optimized and continued on nitro gtt post
procedure for blood pressure control as symptoms had resolved
prior to cath. Echo showed Normal biventricular size and global
systolic function. Mild to moderate tricuspid regurgitation.
#Hematoma: Patient complained of groin pain at cath site, though
no tenderness to palpation or signs of hematoma. He was found to
have a small RP hematoma which was not significant in size and
therefore was managed expectantly.
Chronic Issues:
# CAD. s/p 3V CABG in ___. LIMA graft to the LAD and vein
grafts to a circumflex marginal and the distal right coronary
artery. Continued on ASA, metoprolol, and Atorvastatin.
# CKD. Patient's Cr 1.4 appears to be baseline. Cr 1.3 in ___
and per PCP note, recent admission to ___ Cr was 1.4
# HTN: continued amlodipine at home dose 2.5 BID
# DM type II: continued on home lantus 40mg QHS, held 70/30
whiel inpatient and given ISS with adequate control of blood
glucose.
# HLD: Atorvasatin as above was continued.
# Esosinophillia. Patient has had chronic esosinophilla. Given
country of origin, sent Strongyloides IgG, pending at time of
discharge.
# ___ disease: continued on home dose Carbidopa-Levodopa.
Transitional Issues
#Consider transitioning to metoprolol succinate as an
outpatient, and uptitration as needed. Could consider carvedilol
for better HTN and rate control
#Imdur uptitrated to assist with angina, cont as needed as an
outpatient
___ not used given hx of hyperkalemia
###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, chest
pain {Chest pain}, shortness of breath {Dyspnea}, Chest pain {Chest pain}, trops {Troponin measurement}, V5 {Lead site V5}, V6 {Lead site V6}, EKG {Electrocardiographic procedure}, ischemia {Ischemia}, diuresed {Diuretic therapy}, shortness of breath {Dyspnea}, improvement {Patient's condition improved}, angiogram {Angiography}, occluded {Complete obstruction}, SVG {Aortocoronary artery bypass graft with saphenous vein graft}, OM {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, chronic {Chronic total occlusion of coronary artery}, cath {Cardiac catheterization}, Echo {Echocardiography}, biventricular {Cardiac ventricular structure}, size {Normal size}, systolic function {Normal left ventricular systolic function and wall motion}, Mild {Mild tricuspid valve regurgitation}, moderate tricuspid regurgitation {Moderate tricuspid valve regurgitation}, Hematoma {Hematoma}, groin pain {Inguinal pain}, cath site {Vascular catheter insertion site}, tenderness to palpation {Abdominal tenderness}, signs {Sign}, hematoma {Hematoma}, RP hematoma {Retroperitoneal hematoma}, CAD {Coronary arteriosclerosis}, 3V CABG {Coronary artery bypass grafts x 3}, LIMA graft {Coronary artery bypass grafting using free left internal thoracic artery graft}, LAD {Structure of anterior descending branch of left coronary artery}, vein
grafts {Venous graft}, circumflex marginal {Structure of obtuse marginal branch of circumflex branch of left coronary artery}, distal right coronary
artery {Structure of distal portion of right coronary artery}, CKD {Chronic kidney disease}, Cr {Finding of creatinine level}, Cr {Finding of creatinine level}, Cr {Finding of creatinine level}, HTN {Hypertensive disorder, systemic arterial}, DM type II {Diabetes mellitus type 2}, HLD {Hyperlipidemia}, Esosinophillia {Eosinophil count above reference range}, esosinophilla {Eosinophil count above reference range}, HTN {Hypertensive disorder, systemic arterial}, angina {Angina}, hyperkalemia {Hyperkalemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 200 mg PO DAILY
5. Senna 17.2 mg PO BID:PRN constipation
6. Atorvastatin 40 mg PO QPM
7. Amlodipine 2.5 mg PO BID
8. Carbidopa-Levodopa (___) 2 TAB PO TID
9. 70/30 25 Units Breakfast
70/30 25 Units Dinner
Humalog 40 Units Bedtime
Discharge Medications:
1. Amlodipine 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carbidopa-Levodopa (___) 2 TAB PO TID
5. Docusate Sodium 200 mg PO DAILY
6. 70/30 25 Units Breakfast
70/30 25 Units Dinner
Humalog 40 Units Bedtime
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Metoprolol Tartrate 50 mg PO BID
9. Senna 17.2 mg PO BID:PRN constipation
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.4 mg 1 tablet(s) sublingually q5min:prn Disp
#*100 Tablet Refills:*0
11. Cane
LENGTH OF NEED: 13 MONTHS
EQUIPMENT: STANDARD CANE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Chest pain
Coronary ARtery Disease
Secondary Diagnoses:
Chronic Kidney Disease
DIabetes Mellitus, Type 2
Hypertension
Hyperlipidemia
___ Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Home With Service {Home health aide service management}, Chest pain {Chest pain}, Coronary ARtery Disease {Coronary arteriosclerosis}, Chronic Kidney Disease {Chronic kidney disease}, DIabetes Mellitus, Type 2 {Diabetes mellitus type 2}, Hypertension {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted for chest pain in the presence of complex
coronary disease. You had changes in your EKG which was
concerning for new blockage and were taken for a cardiac
catherization. You were found to have a chronically occluded
vessel from your previous coronary bypass surgery. An echo was
ordered, but was not obtained to monitor your heart function and
should be ordered by your primary cardiologist if desired. You
were having groin pain which kept you in the hospital for one
additional night and was controlled.
We have increased your dose of imdur. You should continue your
remaining medications.
Please follow up with your PCP/cardiologist next week. Please
call your PCP on the next business day to make an appointment.
He is aware of your hospitalization.
Please be well.
Your ___ Team
###RESPONSE: chest pain {Chest pain}, coronary disease {Coronary arteriosclerosis}, EKG {Electrocardiographic procedure}, blockage {Coronary occlusion}, cardiac
catherization {Cardiac catheterization}, occluded
vessel {Coronary artery bypass graft occlusion}, coronary bypass surgery {Coronary artery bypass grafting}, echo {Echocardiography}, groin pain {Inguinal pain}, increased {Increasing dosage of medication} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Chest Discomfort
Major Surgical or Invasive Procedure:
None
###RESPONSE: Aspirin {Allergy to aspirin}, Chest Discomfort {Chest discomfort} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
EVENTS / HISTORY OF PRESENTING ILLNESS: The pt is a ___ F with
PMH of Asthma admitted with complains of sub-scapular chest pain
radiating to the back for the past week. Pain has been constant
in nature, with cramping. No numbness/tingling in the arms and
legs. Pt Pt reports her symptoms began two weeks ago after
breaking into fever, did not take temp., and night sweats. She
then developed diffuse muscles aches greatest over her breasts,
chest wall and upper extremities b/l. Denies changes with
position. States it is mildly worse with deep inspiration. She
does report increased physical activity over the past two weeks
with ___ cleaning. Denies pain at rest. She denies recent
sick contacts. No travel history. Reports night sweats for past
two weeks. The pt does relate significant EtOH history, drinking
approx 1 glass of wine every other day, then on the weeks she
drinks one bottle on ___, then ___ gladsses on ___.
Reports remote cocaine history, clean for past ___ years. Pt
reports history of asthma, no change is symptoms and no increase
in albuterol usage, reports no change of symptoms with exertion,
does have occassional dyspnea.
.
In the ED, Vitals T 98.4, HR 72, RR 18, BP 121/98, Sat 95% RA.
She was given aspirin 325mg daily and motrin 600mg once. On
arrival to the floor the patient is resting comfortably and in
no acute distress.
.
.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, joint pains, cough, hemoptysis, black stools or
red stools. She denies exertional buttock or calf pain. All of
the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
###RESPONSE: Asthma {Asthma}, chest pain {Chest pain}, radiating {Radiating pain}, Pain {Pain}, constant {Constant pain}, cramping {Cramping pain}, numbness/tingling {Numbness and tingling sensation of skin}, arms {Upper limb structure}, legs {Lower limb structure}, fever {Fever}, temp {Body temperature finding}, night sweats {Night sweats}, diffuse {Diffuse pain}, muscles aches {Muscle pain}, breasts {Breast structure}, chest wall {Chest wall structure}, upper extremities {Upper limb structure}, position {Pain provoked by movement}, worse {Increased pain}, increased physical activity {Increased physical activity}, pain at rest {Pain provoked by rest}, travel {Travel abroad}, night sweats {Night sweats}, EtOH {Alcohol abuse}, drinking {Current drinker of alcohol}, drinks {Current drinker of alcohol}, cocaine {Cocaine abuse}, asthma {Asthma}, exertion {Dyspnea on exertion}, dyspnea {Dyspnea}, Vitals {Vital signs finding}, aspirin {Administration of aspirin}, comfortably {Breathing easily}, no acute {No abnormality detected}, distress {Distress}, review of systems {Review of systems}, stroke {Cerebrovascular accident}, TIA {Transient ischemic attack}, deep venous thrombosis {Deep venous thrombosis}, pulmonary embolism {Pulmonary embolism}, bleeding {Bleeding}, surgery {Surgical procedure}, joint pains {Joint pain}, cough {Cough}, hemoptysis {Hemoptysis}, black stools {Dark stools}, red stools {Red stools}, exertional {Pain provoked by exertion}, buttock {Pain in buttock}, calf pain {Pain in calf}, review of systems {Review of systems}, negative {No pathologic diagnosis}, Cardiac review of systems {Cardiovascular physical examination}, chest pain {Chest pain}, dyspnea on exertion {Dyspnea on exertion}, paroxysmal nocturnal dyspnea {Paroxysmal nocturnal dyspnea}, orthopnea {Orthopnea}, ankle edema {Ankle edema}, palpitations {Palpitations}, syncope {Syncope}, presyncope {Near syncope} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
HTN
Obesity
Endometriosis
Asthma
Stress Incontinence
Cardiac Risk Factors: Hypertension
###RESPONSE: HTN {Hypertensive disorder, systemic arterial}, Obesity {Obesity}, Endometriosis {Endometriosis}, Asthma {Asthma}, Stress Incontinence {Genuine stress incontinence}, Cardiac Risk Factors {Assessment for risk of cardiovascular disease}, Hypertension {Hypertensive disorder, systemic arterial} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
There is a family history of father MI age ___.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS - T 98.8, HR 76, BP 134/62, O2 98%2L
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with flat JVP.
CV: PMI located in ___ intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
TTP over left breast, substernal chest tenderness to palp, also
tenderness over shoulders and triceps
Abd: Soft, NT/ND. No HSM or tenderness. Abd aorta not enlarged
by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ DP 2+ ___ 2+
###RESPONSE: VS {Vital signs finding}, HR {Finding of heart rate}, BP {Blood pressure finding}, Gen {General examination of patient}, WDWN {Well nourished}, middle aged {Middle-age}, NAD {No abnormality detected}, Oriented x3 {Oriented to person, time and place}, Mood {Level of mood - normal}, affect {Mood finding}, HEENT {Physical examination procedure}, NC {Normal head}, Sclera anicteric {White sclera}, PERRL {Pupils equal and reacting to light}, EOMI {Normal ocular motility}, Conjunctiva were
pink {Conjunctiva normal}, pallor {Pallor of skin of face}, cyanosis {Cyanosis}, oral mucosa {Oral mucous membrane structure}, xanthalesma {Xanthelasma}, Neck {Physical examination procedure}, Supple {Normal movement of neck}, JVP {Finding of jugular venous pressure}, CV {Cardiovascular physical examination}, PMI {Finding of apex beat}, intercostal space {Structure of intercostal space}, midclavicular line {Midclavicular line}, RR {Finding of rate of respiration}, normal S1 {Normal first heart sound, S>1<}, S2 {Normal second heart sound, S>2<}, No m/r/g {Heart sounds normal}, thrills {Thrill}, lifts {Precordial heave}, No S3 {Third heart sound, S>3<, inaudible}, Chest {Examination of respiratory system}, chest wall deformities {Deformity of chest wall}, scoliosis {Scoliosis deformity of spine}, kyphosis {Kyphosis deformity of spine}, Resp {Examination of respiratory system}, accessory muscle {Accessory skeletal muscle}, CTAB {Normal breath sounds}, crackles {Respiratory crackles}, wheezes {Wheezing}, rhonchi {Wheeze - rhonchi}, TTP {Tenderness}, left breast {Left breast structure}, substernal {Structure of substernal region}, tenderness {Tenderness}, palp {Palpation of abdomen}, tenderness {Tenderness}, shoulders {Shoulder region structure}, triceps {Triceps brachii muscle structure}, Abd {Examination of abdomen}, Soft {Abdomen soft}, NT {Abdominal tenderness}, ND {Swollen abdomen}, HSM {Hepatosplenomegaly}, tenderness {Tenderness}, Abd {Examination of abdomen}, enlarged {Enlargement}, palpation {Palpation}, abdominial bruits {Abdominal bruit}, Ext {Examination of limb}, No c/c/e {No abnormality detected}, femoral bruits {Femoral bruit}, Skin {Examination of skin}, stasis dermatitis {Stasis dermatitis}, ulcers {Ulcer}, scars {Scar}, xanthomas {Xanthomatosis}, Carotid 2 {Normal carotid arterial pulse}, 2+ DP {Dorsalis pulse present}, Carotid 2 {Normal carotid arterial pulse}, 2+ DP {Dorsalis pulse present} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 03:20PM WBC-4.1# RBC-3.98* HGB-11.6* HCT-34.8* MCV-87
MCH-29.2 MCHC-33.5 RDW-14.0
___ 03:20PM NEUTS-19* BANDS-0 LYMPHS-66* MONOS-10 EOS-4
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 03:20PM PLT SMR-NORMAL PLT COUNT-309
___ 03:20PM ___ PTT-26.1 ___
___ 03:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:20PM TSH-0.90
___ 03:20PM ALT(SGPT)-33 AST(SGOT)-46* CK(CPK)-936* ALK
PHOS-38* TOT BILI-0.2
___ 03:20PM BLOOD ALT-33 AST-46* CK(CPK)-936* AlkPhos-38*
TotBili-0.2
___ 03:20PM BLOOD CK-MB-9 cTropnT-0.03*
___ 09:32PM BLOOD CK(CPK)-777*
___ 09:32PM BLOOD CK-MB-7 cTropnT-0.02*
___ 06:00AM BLOOD CK-MB-5 cTropnT-0.01
___ 06:00AM BLOOD CK(CPK)-609*
.
CXR ___
FINDINGS: Lung volumes are diminished. No consolidation or
superimposed edema is evident. Mild tortuosity of the thoracic
aorta is again demonstrated. The cardiac silhouette is within
normal limits for size accounting for patient and technical
factors. No effusion or pneumothorax is noted. The visualized
osseous structures are unremarkable.
IMPRESSION: Low lung volumes, but otherwise, no superimposed
acute process.
.
EKG demonstrated NSR, Nl axis and intervals, low voltage in AVF,
TWF V5 and V6 with no significant change compared with prior
dated ___.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, NORMAL {No abnormality detected}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated}, ASA {Aspirin specific immunoglobulin E antibody measurement}, NEG {No abnormality detected}, ETHANOL {Blood ethanol measurement}, NEG {No abnormality detected}, ACETMNPHN {Acetaminophen measurement}, NEG {No abnormality detected}, bnzodzpn {Benzodiazepine measurement}, NEG {No abnormality detected}, barbitrt {Barbiturates measurement}, NEG {No abnormality detected}, tricyclic {Tricyclic antidepressant measurement}, NEG {No abnormality detected}, TSH {Thyroid stimulating hormone measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, ALK
PHOS {Alkaline phosphatase measurement}, TOT BILI {Bilirubin, total measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, CK(CPK {Creatine kinase measurement}, AlkPhos {Alkaline phosphatase measurement}, TotBili {Bilirubin, total measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK-MB {Creatine kinase MB isoenzyme measurement}, cTropnT {Troponin T cardiac measurement}, CK(CPK {Creatine kinase measurement}, CXR {Plain chest X-ray}, Lung volumes {Finding of respiratory volume}, consolidation {Consolidation}, edema {Edema}, Mild {Symptom mild}, tortuosity {Tortuosity}, thoracic
aorta {Thoracic aorta structure}, cardiac {Heart structure}, normal {Normal size}, size {Normal size}, effusion {Pleural effusion}, pneumothorax {Pneumothorax}, osseous structures {Bone structure}, unremarkable {Imaging result normal}, lung volumes {Finding of respiratory volume}, EKG {Electrocardiographic procedure}, NSR {Normal sinus rhythm}, axis {Electrocardiographic axis finding}, intervals {Finding of electrocardiogram waveform}, AVF {aVF}, TWF {Flattened T wave}, no significant {No abnormality detected} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Patient is a ___ F with PMH of Asthma admitted with complains
of diffuse muscle aches including sub-scapular chest pain
radiating to the back for the past week, found to have elevated
CK to 936
.
#. Diffuse Musculoskeletal Pain - Pt presented with complaints
of diffuse musculoskeletal pain, worse with movement and found
to have elevated CK to 900s. In reviewing labs pt with
chronically elevated CK of unclear etiology. Etiology may be
recent overuse at home in the setting of deconditioning vs viral
myositis. Pt had recent fever/chills prior to onset of muscle
pain, could be consistent with infectious etiology. Pt may also
have myositis related to EtOH use. She ruled out for myocardial
ischemia with three sets of negative cardiac enzymes. She was
discharged home with close outpatient follow up for further
management.
.
#. Rhythm - NSR
.
#. Asthma - pt denies symptoms of dyspnea currently, no wheezing
on exam. Continued on outpatient regimen of advair and albuterol
.
#. HTN - continue HCTZ
.
###RESPONSE: Asthma {Asthma}, diffuse {Diffuse pain}, muscle aches {Muscle pain}, chest pain {Chest pain}, radiating {Radiating pain}, elevated
CK {Creatine kinase level above reference range}, Diffuse {Diffuse pain}, Musculoskeletal Pain {Musculoskeletal pain}, diffuse {Diffuse pain}, musculoskeletal pain {Musculoskeletal pain}, worse {Increased pain}, elevated CK {Creatine kinase level above reference range}, labs {Laboratory test}, elevated CK {Creatine kinase level above reference range}, viral
myositis {Viral myositis}, fever {Fever}, chills {Chill}, muscle
pain {Muscle pain}, infectious {Infectious disease}, myositis {Myositis}, EtOH use {Finding of alcohol intake}, myocardial
ischemia {Myocardial ischemia}, negative cardiac enzymes {Cardiac enzymes within reference range}, outpatient follow up {Follow-up arranged}, Rhythm {Normal sinus rhythm}, NSR {Normal sinus rhythm}, Asthma {Asthma}, dyspnea {Dyspnea}, wheezing {Wheezing}, exam {Physical examination procedure}, regimen {Therapeutic regimen}, HTN {Hypertensive disorder, systemic arterial} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
CURRENT MEDICATIONS:
Albuterol Sulfate - 0.083 % (0.83 mg/mL) Solution for
Nebulization - 1 vial po every six (6) hours as needed for SOB
Albuterol Sulfate - 90 mcg HFA Aerosol Inhaler - 2 puffs po
every
six (6) hours as needed for SOB
Citalopram - 40 mg Tablet - 1 and ___ Tablet(s) by mouth once a
day
Fluticasone-Salmeterol [Advair Diskus] - 500 mcg-50 mcg/Dose
Disk
with Device - one puff disk twice a day
Hydrochlorothiazide - 25 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
Montelukast [Singulair] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
Medications - OTC
Omeprazole Magnesium [Prilosec OTC] - 20 mg Tablet, Delayed
Release (E.C.) - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for
wheeze/SOB.
2. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every ___ hours as needed for shortness of breath or wheezing.
3. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation once a day.
4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day.
5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Myositis
Discharge Condition:
Afebrile, VSS, ambulating without assistance
###RESPONSE: Myositis {Myositis}, Afebrile {Fever}, VSS {Vital signs finding}, ambulating without assistance {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted with diffuse muscle pain. You have undergone
bloodwork that has demonstrated no evidence of damage to your
heart as a cause of this pain. Your bloodwork did show an
elevation of a muscle enyme called creatine kinase. You will
follow up with Dr. ___ as an outpatient for continued workup.
.
Your medications have not changed. Please continue to take your
medications as directed.
.
Please return or call your primary care physician if you develop
worsening musculoskeletal pain, or if you develop chest pain or
shortness of breath.
###RESPONSE: diffuse {Diffuse pain}, muscle pain {Muscle pain}, no evidence {No abnormality detected}, damage {Damage}, heart {Heart structure}, pain {Pain}, elevation {Measurement finding above reference range}, muscle {Skeletal and/or smooth muscle structure}, called {Informing doctor}, creatine {Creatine measurement}, follow up {Follow-up arranged}, workup {Evaluation procedure}, changed {Change of medication}, primary care {Primary care management}, worsening {Increased pain}, musculoskeletal pain {Musculoskeletal pain}, chest pain {Chest pain}, shortness of breath {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal
/ naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa
(Sulfonamide Antibiotics) / golytely / citrate of magnesia /
Lithium
Attending: ___.
Chief Complaint:
diverticulitis
Major Surgical or Invasive Procedure:
none
###RESPONSE: Amoxicillin {Allergy to amoxicillin}, Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, Codeine {Allergy to codeine}, ibuprofen {Allergy to ibuprofen}, Tetanus {Tetanus}, Sulfonamide Antibiotics {Allergy to sulfonamide antibiotic}, diverticulitis {Diverticulitis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with multiple medical problems, including ESRD ___ lithium
toxicity on PD , admitted to ___ on ___ with abdominal
pain and fever to 102 at home. She had a prior admission on
___ with similar symptoms; at that time the workup was
negative and she was give levofloxacin x5 days for presumptive
pneumonia. On representation to ___, her WBC was elevated
to 16.5. Peritoneal fluid was sent and demosntrated ___ WBC with
no organisms on gram stain. A CT scan was obtained with
demonstrated diverticulitis and likely contained perforation
with concern for pelvic abscess. She was started on levaquin and
flagyl and recommended for percutanous drainage. However given
her extensive past surgical history here at ___, the family
requested transfer to ___ for further work up and
management.
ROS: Endorses 20lb wt loss over the past few months
###RESPONSE: problems {Problem}, ESRD {End-stage renal disease}, lithium
toxicity {Lithium poisoning}, abdominal
pain {Abdominal pain}, fever {Fever}, workup {Evaluation procedure}, pneumonia {Pneumonia}, gram stain {Gram stain method}, CT scan {Computed tomography}, diverticulitis {Diverticulitis}, perforation {Perforation}, pelvic abscess {Pelvic abscess}, drainage {Drainage procedure}, surgical {Surgical procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMH: tracheostomy ___ for prolonged respiratory failure,
hyponatremic seizure following GoLytely prep ___, ESRD for
lithium toxicity, on HD, bipolar, GERD, HTN, breast cancer,
diverticulosis
PSH: parathyroidectomy with reimplantation in left arm, left
foot surgery in ___, right knee surgery in ___, lumpectomy for
breast cancer (DCIS), status post radiation, repeat mammograms
were all negative, history of tonsillectomy in the past.
###RESPONSE: tracheostomy {Exteriorization of trachea}, respiratory failure {Respiratory failure}, seizure {Seizure}, ESRD {End-stage renal disease}, lithium toxicity {Lithium poisoning}, HD {Hemodialysis}, GERD {Gastroesophageal reflux disease}, HTN {Hypertensive disorder, systemic arterial}, breast cancer {Malignant neoplasm of breast}, diverticulosis {Diverticulosis of large intestine}, parathyroidectomy {Parathyroidectomy}, reimplantation {Reimplantation}, left arm {Left upper arm structure}, left
foot {Structure of left foot}, surgery {Surgical procedure}, right knee {Structure of right knee region}, surgery {Surgical procedure}, lumpectomy {Excision of mass}, breast cancer {Malignant neoplasm of breast}, radiation {Radiation oncology AND/OR radiotherapy}, mammograms {Mammography}, tonsillectomy {Tonsillectomy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother with ovarian CA
Father with CAD
###RESPONSE: ovarian {Malignant tumor of ovary}, CAD {Coronary arteriosclerosis} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
VS: 99.1 73 117/64 18 100%ra
PE:
Gen: A&Ox3, NAD, pleasant and comfortable appearing
CV: RRR
Pulm: CTAB, easy WOB
Abd: abd soft, mildly distended. PD catheter site in RLQ.
Mildly
TTP RUQ/LUQ/LLQ, worst in LLQ.
Ext: WWP, trace periph edema bilat, L > R
###RESPONSE: VS {Vital signs finding}, Gen {General examination of patient}, Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, Pulm {Examination of respiratory system}, CTAB {Normal breath sounds}, WOB {Breathing easily}, Abd {Examination of abdomen}, abd soft {Abdomen soft}, distended {Swollen abdomen}, RLQ {Right lower quadrant pain}, TTP {Thrombotic thrombocytopenic purpura}, RUQ {Structure of right upper quadrant of abdomen}, LUQ {Structure of left upper quadrant of abdomen}, LLQ {Structure of left lower quadrant of abdomen}, LLQ {Structure of left lower quadrant of abdomen}, Ext {Examination of limb}, WWP {Normal tissue perfusion}, edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 09:15PM GLUCOSE-87 UREA N-52* CREAT-10.1*#
SODIUM-132* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-29 ANION GAP-14
___ 09:15PM ALT(SGPT)-17 AST(SGOT)-15 ALK PHOS-311* TOT
BILI-0.2
___ 09:15PM ALBUMIN-2.5* CALCIUM-7.6* PHOSPHATE-4.3
MAGNESIUM-1.6
___ 09:15PM LITHIUM-0.9
___ 09:15PM WBC-5.4 RBC-2.32*# HGB-7.4*# HCT-25.1*#
MCV-108* MCH-31.9 MCHC-29.4* RDW-19.1*
___ 09:15PM NEUTS-77.4* LYMPHS-12.7* MONOS-7.0 EOS-2.7
BASOS-0.1
___ 09:15PM ___ PTT-31.5 ___
###RESPONSE: GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, ALBUMIN {Albumin measurement}, CALCIUM {Blood calcium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, PTT {Partial thromboplastin time, activated} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Ms. ___ was admitted to the Transplant Surgery Service
under the care of Dr. ___ on ___. She
was transferred from ___ in ___ with
a colonic microperforation in the setting of diverticulitis.
This was of particular concern given her concurrent use of
peritoneal dialysis for renal replacement therapy for her long
standing history of ESRD. Upon admission, physical exam and
vital signs were un concerning for systemic infection. She was
afebrile, did not have evidence of cellulitis around her PD
catheter exit site, and did not have leukocytosis.
Levofloxacin and metronidazole were administered to treat Ms.
___ diverticulitis. She was kept NPO. Abdominal pain
resolved. Nephrology followed and managed the peritoneal
dialysis adding heparin for fibrin in dialysate. Diet was
resumed and well tolerated.
Throughout the course of her admission, Ms. ___ home
medications to treat her psychiatric and medical co morbidities
were continued. Vital signs remained stable, she was pain free
and was oob to chair with assist.
She will f/u with her local nephrologist. Vitamin D and
calcitriol were started and Cinacalcet stopped. Atenolol and
Nifedipine were also stopped for SBPs in ___. Heart rates ranged
between ___. She was instructed to f/u with her
nephrologist.
###RESPONSE: colonic microperforation in the setting of diverticulitis {Diverticulitis of colon with perforation}, peritoneal dialysis {Peritoneal dialysis}, renal replacement therapy {Continuous renal replacement therapy}, ESRD {End-stage renal disease}, vital signs {Vital signs finding}, systemic infection {Sepsis}, cellulitis {Cellulitis}, catheter exit site {Catheter exit site}, leukocytosis {Leukocytosis}, diverticulitis {Diverticulitis}, NPO {Nil by mouth}, Abdominal pain {Abdominal pain}, peritoneal
dialysis {Peritoneal dialysis}, Diet {Dietary finding}, medications {Administration of drug or medicament}, psychiatric {Psychiatric symptom}, Vital signs {Vital signs finding}, stable {Normal vital signs}, Heart rates {Finding of heart rate} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
fluoxetine 20 qam, lithium 150 qam 150qpm prn, goal level 0.7.
antenerol 25 qpm. zyprexa 10mg qpm, ___ prn for agitation,
dialyvite 800 qam, iron 65mg qd, prilosec 20mg BID, topiramate
25mg qpm, colace 100mg BID, procrit 40,000 ___, sensipar 30mg
qd, senna prn, renvela TID with meals
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Fluoxetine 20 mg PO DAILY
3. Lithium Carbonate 150 mg PO DAILY
4. OLANZapine 10 mg PO DAILY
additional doses PRN agitation
5. Omeprazole 20 mg PO BID
6. Calcitriol 0.25 mcg PO DAILY
RX *calcitriol 0.25 mcg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*2
7. Heparin Flush (1000 units/mL) 1000 UNIT DWELL QID
each 1 liter dwell IP for fibrin
8. Lactulose 30 mL PO BID
RX *lactulose 20 gram/30 mL 30 ml by mouth twice a day Disp #*1
Bottle Refills:*2
9. Levofloxacin 250 mg PO Q24H Duration: 8 Days
RX *levofloxacin [Levaquin] 250 mg 1 tablet(s) by mouth once a
day Disp #*8 Tablet Refills:*0
10. Lorazepam 1 mg PO HS:PRN insomnia
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*24 Tablet Refills:*0
12. Miconazole Powder 2% 1 Appl TP BID
13. Tucks Hemorrhoidal Oint 1% 1 Appl PR PRN hemorrhoidal pain
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth once a week Disp #*12 Capsule Refills:*0
15. Epoetin Alfa 40,000 units SC Q ___
16. Senna 1 TAB PO BID:PRN constipation
17. OLANZapine 5 mg PO ASDIR
Please assess patient for leg tingling, restlessness and give
this additional dose. Will likely need while doing CAPD
18. Topiramate (Topamax) 25 mg PO DAILY
19. DIALYVITE 800 *NF* (B complex-C-folic acid-Zn) 0.8 mg Oral
Daily
20. Ferrous Sulfate 325 mg PO DAILY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
diverticulitis
colonic microperforation
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
###RESPONSE: diverticulitis {Diverticulitis}, colonic {Colon structure}, ESRD {End-stage renal disease}, Mental Status {Neurological mental status determination}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Ambulatory - requires assistance or aid {Finding of walking aid use} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Please call Dr. ___ office ___ if you have
any of the following: temperature of 101 or greater, chills,
increased abdominal pain, nausea, vomiting, peritoneal effluent
appears cloudy or bloody, or has a foul smell, bloody stool or
diarrhea
-continue with peritoneal dialysis
-finish antibiotics as prescribed
-atenolol and nifedipine stopped for low blood pressure
###RESPONSE: chills {Chill}, abdominal pain {Abdominal pain}, nausea, vomiting {Nausea and vomiting}, peritoneal effluent
appears cloudy or bloody {Peritoneal fluid abnormal}, bloody stool {Hematochezia}, diarrhea {Diarrhea}, peritoneal dialysis {Peritoneal dialysis}, antibiotics {Antibiotic therapy}, low blood pressure {Low blood pressure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
vancomycin in D5W
Attending: ___.
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
None
###RESPONSE: lightheadedness {Lightheadedness} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of COPD on 2L NC, CAD s/p CABG, DM, afib s/p ablation,
who presents with lightheadedness.
Per patient, he notes that he "felt like I was having a stroke".
He said that just prior to presentation he got up out of the car
and felt like he was going to fall down and that the ground was
rushing up at him. He sat back down in the car and the feeling
subsided in ___ minutes. He denies a spinning sensation or a
disequilibrium type feeling. No chest pain, SOB, palpitations,
f/c/s. No numbness, tingling, LOS or weakness anywhere.
He reports he has similar episodes ___, in which he
experiences symptoms like he is being "electrocuted." He calls
these mini-strokes, though he does not have a h/o CVA. He has
not seen a neurologist for these given infrequency; he has
discussed this with his PCP.
Currently he feels well without complaints or concerns. No
further episodes. Denies current dizziness, headache, fevers,
cough, chest pain, abd pain, N/V/D, or double vision. He checks
his fingersticks weekly and they have been running between
120-140s. No recent medication changes.
In the ED, VSS. He had a head CT which was wnl. Labs were
notable for Cr 2.1, elevated from his baseline, so he received 1
liter of LR in the ED. He also had positive orthostatics while
there.
###RESPONSE: COPD {Chronic obstructive lung disease}, 2L NC {Oxygen administration by nasal cannula}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, DM {Diabetes mellitus}, afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, lightheadedness {Lightheadedness}, spinning sensation {Vertigo}, chest pain {Chest pain}, SOB {Dyspnea}, palpitations {Palpitations}, numbness, tingling {Numbness and tingling sensation of skin}, LOS {Loss of consciousness}, weakness {Asthenia}, CVA {Cerebrovascular accident}, feels well {Well in self}, dizziness {Dizziness}, headache {Headache}, fevers {Fever}, cough {Cough}, chest pain {Chest pain}, abd pain {Abdominal pain}, N/V/D {Nausea, vomiting and diarrhea}, double vision {Diplopia}, medication changes {Change of medication}, VSS {Vital signs finding}, head CT {Computed tomography of head}, baseline {Baseline state}, orthostatics {Orthostatic body position} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Asthma/COPD
CAD status post CABG
Atrial fibrillation status post ablation
PVD status post subclavian artery stent
Right shoulder osteoarthritis
Cataracts
Osteoporosis
Chronic kidney injury
Diabetes mellitus
Hypertension
Cholelithiasis
Allergic rhinitis
History of alcohol misuse
History of cognitive deficits
History of depression
###RESPONSE: Asthma {Asthma}, COPD {Chronic obstructive lung disease}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, Atrial fibrillation {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, PVD {Peripheral vascular disease}, subclavian artery stent {Insertion of stent into subclavian artery}, Right shoulder {Structure of right shoulder region}, osteoarthritis {Osteoarthritis}, Cataracts {Cataract}, Osteoporosis {Osteoporosis}, Chronic kidney injury {Chronic kidney disease}, Diabetes mellitus {Diabetes mellitus}, Hypertension {Hypertensive disorder, systemic arterial}, Cholelithiasis {Calculus in biliary tract}, Allergic rhinitis {Allergic rhinitis}, alcohol misuse {Alcohol abuse}, cognitive deficits {Impaired cognition}, depression {Depressive disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Mother with lung cancer and father with CVA.
###RESPONSE: lung cancer {Malignant tumor of lung}, CVA {Cerebrovascular accident} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable except for SBP 180s
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM
slightly dry.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable except for SBP 180s
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM
slightly dry.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
###RESPONSE: VITALS {Vital signs finding}, vital signs {Vital signs finding}, stable {Normal vital signs}, SBP {Blood pressure finding}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Abdominal tenderness}, Ears {Ear structure}, nose {Nasal structure}, erythema {Erythema}, masses {Mass of body structure}, trauma {Traumatic injury}, Oropharynx {Oropharyngeal structure}, lesion {Lesion}, erythema {Erythema}, exudate {Exudate}, MM
slightly dry {Mucous membrane dryness}, CV {Cardiovascular physical examination}, Heart {Cardiovascular physical examination}, murmur {Murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, JVD {Jugular venous engorgement}, RESP {Examination of respiratory system}, Lungs {Examination of respiratory system}, GI {Examination of digestive system}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, non-tender {Abdominal tenderness}, palpation {Palpation}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness {Tenderness}, palpation {Palpation}, supple {Normal movement of neck}, all extremities {All extremities}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, rashes {Eruption of skin}, ulcerations {Ulcer}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Orientated}, face symmetric {Facial symmetry}, EOMI {Normal ocular motility}, speech fluent {Does speak fluently}, moves all limbs {Does move all four limbs}, sensation to light touch grossly
intact {Normal light touch sensation}, affect {Mood finding}, VITALS {Vital signs finding}, vital signs {Vital signs finding}, stable {Normal vital signs}, GENERAL {General examination of patient}, Alert {Mentally alert}, distress {Distress}, Anicteric {White sclera}, pupils equally round {Pupil size and shape normal}, ENT {Ear, nose and throat examination}, Ears {Ear structure}, nose {Nasal structure}, erythema {Erythema}, masses {Mass of body structure}, trauma {Traumatic injury}, Oropharynx {Oropharyngeal structure}, lesion {Lesion}, erythema {Erythema}, exudate {Exudate}, CV {Cardiovascular physical examination}, Heart regular {Normal sinus rhythm}, murmur {Heart murmur}, no S3 {Third heart sound, S>3<, inaudible}, no S4 {Fourth heart sound, S>4<, inaudible}, RESP {Examination of respiratory system}, Lungs clear to auscultation {Normal breath sounds}, GI {Examination of digestive system}, Abdomen soft {Abdomen soft}, non-distended {Normal abdominal contour}, tender to palpation {Abdominal tenderness}, Bowel
sounds present {Normal bowel sounds}, HSM {Hepatosplenomegaly}, GU {Examination of genitourinary system}, suprapubic {Hypogastric region structure}, tenderness to palpation {Tenderness}, moves all extremities {Does move all four limbs}, symmetric bilaterally in all limbs {Normal bilateral upper limbs and bilateral lower limbs}, SKIN {Examination of skin}, rashes {Eruption of skin}, ulcerations {Ulcer}, NEURO {Neurological examination}, Alert {Mentally alert}, oriented {Oriented to person}, face symmetric {Facial symmetry}, EOMI {Normal ocular motility}, speech fluent {Does speak fluently}, moves all limbs {Does move all four limbs}, sensation to light touch grossly
intact {Normal light touch sensation}, appropriate affect {Appropriate affect} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-8.0 RBC-4.44* Hgb-14.3 Hct-44.3
MCV-100* MCH-32.2* MCHC-32.3 RDW-13.3 RDWSD-48.7* Plt ___
___ 11:20AM BLOOD Neuts-56.5 ___ Monos-13.0 Eos-6.1
Baso-0.9 Im ___ AbsNeut-4.53 AbsLymp-1.87 AbsMono-1.04*
AbsEos-0.49 AbsBaso-0.07
___ 11:20AM BLOOD Glucose-125* UreaN-35* Creat-2.1* Na-139
K-4.6 Cl-104 HCO3-18* AnGap-17
___ 11:20AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.4
___ 11:40AM BLOOD Lactate-2.4*
DISCHARGE LABS:
___ 06:22AM BLOOD Glucose-113* UreaN-29* Creat-1.5* Na-141
K-4.9 Cl-109* HCO3-18* AnGap-14
___ 06:22AM BLOOD WBC-7.3 RBC-4.29* Hgb-14.3 Hct-43.1
MCV-101* MCH-33.3* MCHC-33.2 RDW-13.1 RDWSD-48.0* Plt ___
NCHCT: There is a large CSF density lesion in the right middle
cranial fossa
unchanged from prior and most likely representing a large
arachnoid cyst.
There is no intra-axial or extra-axial hemorrhage, edema, shift
of normally
midline structures, or evidence of acute major vascular
territorial
infarction. Age related involutional changes are again noted.
Ventricles are
stable in size. Minimal periventricular white matter
hypodensities are again
noted consistent with chronic microvascular ischemic disease.
The imaged bony
structures are intact. Imaged paranasal sinuses, mastoid air
cells and middle
ear cavities appear well aerated. Dense carotid siphon
calcification is
noted.
IMPRESSION:
No acute intracranial process. Large arachnoid cyst within the
right middle
cranial fossa.
###RESPONSE: WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, Neuts {Neutrophil count}, Monos {Monocyte count}, Eos {Eosinophil count}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Calcium {Blood calcium measurement}, Phos {Phosphate, total measurement}, Mg {Blood magnesium measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NCHCT {Computed tomography of head without contrast}, density {Abnormally opaque structure}, lesion {Lesion}, middle
cranial fossa {Structure of middle fossa of cranial cavity}, arachnoid cyst {Arachnoid cyst}, intra-axial or extra-axial hemorrhage {Cerebral hemorrhage}, edema {Edema}, shift
of normally
midline structures {Midline shift of brain}, vascular
territorial {Vascular structure within brain}, infarction {Infarct}, Ventricles {Brain ventricle structure}, periventricular white matter {Structure of periventricular white matter}, chronic {Chronic disease}, ischemic disease {Ischemia}, paranasal sinuses {Nasal sinus structure}, mastoid air
cells {Structure of mastoid cell}, middle
ear cavities {Middle ear structure}, carotid siphon {Structure of carotid siphon}, calcification {Pathologic calcification, calcified structure}, arachnoid cyst {Arachnoid cyst}, middle
cranial fossa {Structure of middle fossa of cranial cavity} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ male with PMH of COPD on 2L NC,
CAD s/p CABG, DM, Afib s/p ablation, who presents with
lightheadedness and was found to have ___ and orthostatic
hypotension.
ACUTE/ACTIVE PROBLEMS:
# Lightheadedness/presyncope: Neuro exam was normal on
admission. He did not have arrhythmias or signs of ischemia on
EKG and telemetry overnight was without arrhythmia. NCHCT was
normal, without evidence of stroke/bleed. Based on history, his
episode appeared more consistent with presyncope, and
orthostatic vital signs support this diagnosis. He also had ___
that improved with IVF which is evidence of dehydration though
he denies that he has had reduced intake. Even though ___
improved, he continued to have orthostatic VS with SBP going
from 160 to 100 from lying to standing. Could possibly have
autonomic dysfunction as he does not appear dehydrated anymore.
# ___ on CKD stage III - His Cr was elevated at 2.1 which
improved to 1.5 with 1L IVF which is his baseline. Losartan was
held on admission but restarted at discharge.
#Orthostatic hypotension: Patient had positive orthostatic vital
signs on admission and also after IVF, concerning for some
possible autonomic dysfunction versus medication effect. Now
that Cr is improved, will discharge on losartan for HTN, but
will hold amlodipine as it can worsen orthostatic hypotension.
#Metabolic acidosis: Bicarb was 18 even with improvement in ___.
Based on prior nephrology note, has history of metabolic
acidosis which had been attributed to his CKD. Continue to
monitor and follow up with ___ clinic.
#Macrocytic anemia: Has normal Hgb but with MCV elevated to low
100s. VitB12 and folate in the past few years have been normal.
Could possibly be due to alcohol intake. No diagnosis of liver
disease, but hasn't had an ultrasound in ___ records. MDS is
also on differential.
CHRONIC/STABLE PROBLEMS:
# CAD s/p CABG - continued ASA, ezetimibe
# COPD on 2L - continued advair, albuterol prn, loratidine
# Afib - s/p ablation
# DM - ___ qid, placed on SS in hospital, held Januvia. Restarted
Januvia on discharge.
TRANSITIONAL ISSUES:
- For syncope work up, could consider TTE as outpatient, though
no evidence of valvular abnormality on cardiac exam. Last TTE
was ___.
- Follow up BP and increase medications as needed, but would
avoid CCB and beta blockers due to potential to worsen
orthostatic hypotension
- Should have evaluation for macrocytic anemia. Consider liver
ultrasound. Has follow up with hematology in ___.
- Repeat Cr at next clinic visit.
###RESPONSE: COPD {Chronic obstructive lung disease}, 2L NC {Oxygen administration by nasal cannula}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, DM {Diabetes mellitus}, Afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, lightheadedness {Lightheadedness}, orthostatic
hypotension {Orthostatic hypotension}, Lightheadedness {Lightheadedness}, presyncope {Near syncope}, Neuro exam was normal {Normal nervous system function}, arrhythmias {Cardiac arrhythmia}, signs {Sign}, ischemia {Ischemia}, EKG {Electrocardiographic procedure}, telemetry {Electroencephalogram telemetry}, arrhythmia {Cardiac arrhythmia}, NCHCT {Computed tomography of head without contrast}, stroke {Cerebrovascular accident}, bleed {Hemorrhage}, presyncope {Near syncope}, orthostatic {Orthostatic body position}, vital signs {Vital signs finding}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, dehydration {Dehydration}, improved {Patient's condition improved}, orthostatic {Orthostatic body position}, dehydrated {Dehydration}, CKD stage III {Chronic kidney disease stage 3}, improved {Patient's condition improved}, IVF {Administration of intravenous fluids}, baseline {Baseline state}, Orthostatic hypotension {Orthostatic hypotension}, orthostatic {Orthostatic body position}, vital
signs {Vital signs finding}, IVF {Administration of intravenous fluids}, improved {Patient's condition improved}, HTN {Hypertensive disorder, systemic arterial}, orthostatic hypotension {Orthostatic hypotension}, Metabolic acidosis {Metabolic acidosis}, metabolic
acidosis {Metabolic acidosis}, CKD {Chronic kidney disease}, Macrocytic anemia {Macrocytic anemia}, normal Hgb {Hemoglobin within reference range}, MCV elevated {Mean corpuscular volume above reference range}, liver
disease {Disorder of liver}, ultrasound {Ultrasonography}, MDS {Myelodysplastic syndrome}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, COPD {Chronic obstructive lung disease}, Afib {Atrial fibrillation}, ablation {Catheter ablation of arrhythmogenic focus}, DM {Diabetes mellitus}, syncope {Syncope}, TTE {Transthoracic echocardiography}, no evidence {No abnormality detected}, valvular abnormality {Valvular insufficiency}, cardiac exam {Cardiovascular physical examination}, TTE {Transthoracic echocardiography}, orthostatic hypotension {Orthostatic hypotension}, evaluation {Evaluation procedure}, macrocytic anemia {Macrocytic anemia}, liver {Disorder of liver}, ultrasound {Ultrasonography} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. BuPROPion XL (Once Daily) 150 mg PO BID
3. Mirtazapine 15 mg PO QHS
4. Ezetimibe 10 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
symptoms
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Aspirin 325 mg PO DAILY
12. Loratadine 10 mg PO DAILY
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. BuPROPion XL (Once Daily) 150 mg PO BID
5. Ezetimibe 10 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN allergy
symptoms
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Loratadine 10 mg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Mirtazapine 15 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Home
Discharge Diagnosis:
Acute kidney injury
Pre-syncope
Orthostatic hypotension versus autonomic dysfunction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Acute kidney injury {Acute kidney injury}, Pre-syncope {Near syncope}, Orthostatic hypotension {Orthostatic hypotension}, Mental Status {Neurological mental status determination}, Clear {Normal breath sounds}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for an episode of feeling like you
were going to pass out.
You were found to have acute kidney injury, likely due to
dehydration. You received IV fluids and your kidney function
improved back to normal.
You were also found to have orthostatic hypotension, which means
that your blood pressure gets low when you stand. You need to go
from sitting to standing very slowly and walk carefully when you
are out of the hospital so you do not pass out/faint.
Sincerely,
Your ___ Team
###RESPONSE: acute kidney injury {Acute kidney injury}, dehydration {Dehydration}, IV fluids {Administration of intravenous fluids}, kidney function
improved back to normal {Normal renal function}, orthostatic hypotension {Orthostatic hypotension}, blood pressure {Finding of increased blood pressure}, stand {Does stand}, sitting {Sitting position}, standing {Orthostatic body position} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
CABG ___
###RESPONSE: No Known Allergies {Allergic disposition}, Adverse Drug Reactions {Propensity to adverse reactions to drug}, Chest pain {Chest pain}, CABG {Coronary artery bypass grafting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ year old man with a history of diabetes,
hyperlipidemia, hypertension, and smoking. Over the past two
weeks, he noted multiple episodes of chest pain mostly occuring
at rest. He described the pain as retrosternal, radiating to his
face and left jaw, lasting minutes to an hour, and occuring ___
times per day. On the morning of presentation, he had more of a
grabbing/pressure like pain in his left chest. He also endorsed
headache and shortness of breath. He presented to the emergency
department for further evaulation. A CTA was performed to rule
out dissection and was negative. Initial troponin was positive
at 0.24. An EKG demonstrated a right bundle branch block and ST
depressions in leads V4-V6. Cardiology was consulted in the ER
and he was started on IV heparin with plan for cardiac
catheterization. Cardiac catheterization revealed multivessel
coronary artery disease and he was referred to cardiac surgery
for evaluation.
###RESPONSE: diabetes {Diabetes mellitus}, hyperlipidemia {Hyperlipidemia}, hypertension {Hypertensive disorder, systemic arterial}, smoking {Smoker}, chest pain {Chest pain}, pain {Pain}, retrosternal {Retrosternal pain}, radiating {Radiating pain}, face {Face structure}, jaw {Pain radiating to jaw}, pressure {Tight chest}, pain {Chest pain}, left chest {Structure of left half of chest wall}, headache {Headache}, shortness of breath {Dyspnea}, evaulation {Evaluation procedure}, CTA {Computed tomography angiography with contrast}, EKG {Electrocardiographic procedure}, right bundle branch block {Right bundle branch block}, ST
depressions {ST segment depression}, leads V4 {Lead site V4}, V6 {Lead site V6}, cardiac
catheterization {Cardiac catheterization}, Cardiac catheterization {Cardiac catheterization}, coronary artery disease {Coronary arteriosclerosis}, evaluation {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMHx:
1. Hypertension, essential [401.9] ___ new RBBB on routine EKG.
___: adenosine MIBI neg for ischemia.
2. DM (diabetes mellitus), type 2 with neurological
complications [250.60]
3. Hypercholesterolemia [272.0] ___
4. OBESITY UNSPEC [278.00] ___
5. GAIT ABNMLTY [781.2] ___
6. IMPOTENCE DUE TO ERECTILE DYSFUNCTION [607.84] ___
7. SLEEP APNEA - OBSTRUCTIVE [327.23] ___. Stopped CPAP
8. MENIERE'S DISEASE, UNSPEC [386.00]
9. DERMATITIS - SEBORRHEIC, UNSPEC [690.10]
10. CHRONIC DAILY HEADACHE
PSHx:
___ pilonidal sinus/cyst ___
___ 2.1-3 cm
lipoma on back
Tarsal tunnel release ___
left foot with partial plantar fasciectomy & spur removal
___ ___
left thumb CMC jt
CAD-s/p CABG ___
###RESPONSE: Hypertension, essential {Essential hypertension}, RBBB on routine EKG {Electrocardiographic right bundle branch block}, MIBI {Radionuclide myocardial perfusion study}, ischemia {Ischemia}, DM {Diabetes mellitus}, diabetes mellitus), type 2 {Diabetes mellitus type 2}, neurological
complications {Disorder of nervous system due to diabetes mellitus}, Hypercholesterolemia {Hypercholesterolemia}, OBESITY {Obesity}, GAIT ABNMLTY {Abnormal gait}, ERECTILE DYSFUNCTION {Erectile dysfunction}, SLEEP APNEA - OBSTRUCTIVE {Obstructive sleep apnea syndrome}, CPAP {Continuous positive airway pressure ventilation treatment}, MENIERE'S DISEASE {Ménière's disease}, DERMATITIS {Seborrheic dermatitis}, DAILY HEADACHE {Daily headache}, pilonidal sinus {Hair sinus}, cyst {Pilonidal cyst}, lipoma {Lipoma}, back {Structure of back of trunk}, Tarsal tunnel release {Tarsal tunnel release}, left foot {Structure of left foot}, partial plantar fasciectomy {Partial fasciectomy of plantar fascia}, left thumb {Structure of left thumb}, CMC jt {Carpometacarpal joint structure}, CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non-contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Vitals- 98.1, 142/81, 65, 18, 99% RA
General: NAD, sitting comfortably in bed, jovial and pleasant
HEENT: MMM, EOMI, no icterus
Cardiac: Normocardic, regular, no MRG
Vascular: JVP visible 2-3cm above sternal angle with HOB at 30
degr. Extr wwp with 2+ radial, dp/pt pulses.
Lungs: no incr WOB sitting upright. minimal bibasilar crackles,
incr RR with lying flat but no increase in subjective dyspnea
Abdomen: obese, nontender - otherwise limited by habitus
GU: no foley
Neuro: AOX3, grossly nonfocal
Skin: dry skin on LEs with absent hair, otherwise no lesions
###RESPONSE: Vitals {Vital signs finding}, RA {Breathing room air}, General {General examination of patient}, NAD {No abnormality detected}, sitting {Sitting position}, HEENT {Physical examination procedure}, MMM {Moist oral mucosa}, EOMI {Normal ocular motility}, icterus {Jaundice}, Cardiac {Cardiovascular physical examination}, regular {Normal heart rate}, no MRG {Heart sounds normal}, JVP {Finding of jugular venous pressure}, sternal angle {Structure of sternal angle}, Extr {Limb structure}, 2+ radial {Normal radial pulse}, Lungs {Examination of respiratory system}, WOB {Labored breathing}, sitting {Sitting position}, crackles {Respiratory crackles}, RR {Finding of rate of respiration}, dyspnea {Dyspnea}, Abdomen {Examination of abdomen}, obese {Obese abdomen}, nontender {Abdominal tenderness}, GU {Examination of genitourinary system}, foley {Urinary catheter in situ}, Neuro {Neurological examination}, Skin {Examination of skin}, dry skin {Xeroderma}, absent hair {Hair absent}, lesions {Lesion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
TEE ___:
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
___ or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LV hypertrophy with normal cavity
size, and global systolic function (biplane LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Normal aortic arch
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
___ VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Mild symmetric left ventricular
hypertrophy with normal cavity size, and global systolic
function (biplane LVEF = 55 %). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion. POST-BYPASS:
Preserved biventricular systolic function.
LVEF 55%.
Intact thoracic aorta.
No other new findings.
___ 07:24AM BLOOD WBC-15.7* RBC-4.37* Hgb-13.5* Hct-38.6*
MCV-88 MCH-31.0 MCHC-35.1* RDW-15.2 Plt ___
___ 07:10AM BLOOD WBC-13.6* RBC-4.27* Hgb-13.3* Hct-37.7*
MCV-88 MCH-31.2 MCHC-35.3* RDW-15.1 Plt ___
___ 07:05AM BLOOD WBC-10.3 RBC-3.83* Hgb-12.0* Hct-34.2*
MCV-89 MCH-31.3 MCHC-35.1* RDW-15.1 Plt ___
___ 12:50PM BLOOD Na-133 K-4.4 Cl-95*
___ 07:24AM BLOOD Glucose-155* UreaN-25* Creat-1.2 Na-133
K-5.2* Cl-95* HCO3-22 AnGap-21*
___ 12:50PM BLOOD UreaN-21* Creat-1.1 Na-133 K-4.9 Cl-96
HCO3-26 AnGap-16
___ 07:05AM BLOOD Glucose-114* UreaN-21* Creat-1.1 Na-136
K-5.0 Cl-99 HCO3-25 AnGap-17
___ 06:30AM BLOOD Glucose-85 UreaN-26* Creat-1.1 Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
___ 05:05AM BLOOD Glucose-144* UreaN-27* Creat-0.9 Na-135
K-4.0 Cl-99 HCO3-27 AnGap-13
###RESPONSE: TEE {Transesophageal echocardiography}, thrombus {Thrombus}, RA {Right atrial structure}, RA {Right atrial structure}, ASD {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, LV hypertrophy {Left ventricular hypertrophy}, RV chamber {Structure of cavity of right cardiac ventricle}, free wall motion {Normal ventricular wall motion}, AORTA {Aortic structure}, aortic {Aortic structure}, Focal
calcifications {Focal calcium deposition, calcified structure}, aortic root {Supraaortic valve area structure}, ascending aorta {Ascending aorta structure}, Focal calcifications {Focal calcium deposition, calcified structure}, ascending aorta {Ascending aorta structure}, aortic arch {Aortic arch structure}, AORTIC VALVE {Aortic valve structure}, Mildly thickened {Increased thickness}, aortic valve leaflets {Structure of cusp of aortic valve}, AS {Aortic valve stenosis}, AR {Aortic valve regurgitation}, Mildly thickened {Increased thickness}, mitral valve leaflets {Structure of leaflet of mitral valve}, MR {Mitral valve regurgitation}, tricuspid valve leaflets {Structure of leaflet of tricuspid valve}, PULMONIC VALVE {Pulmonary valve structure}, PULMONARY ARTERY {Pulmonary artery structure}, pulmonic valve leaflet {Structure of cusp of pulmonic valve}, PS {Pulmonic valve stenosis}, PR {Pulmonic valve regurgitation}, PERICARDIUM {Pericardial structure}, pericardial effusion {Pericardial effusion}, thrombus {Thrombus}, left atrium {Left atrial structure}, left atrial appendage {Entire left auricular appendage}, right
atrium {Right atrial structure}, right atrial appendage {Structure of right auricular appendage}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, Mild symmetric left ventricular
hypertrophy {Mild left ventricular hypertrophy}, normal cavity {Normal size cardiac chamber}, Right ventricular chamber {Structure of cavity of right cardiac ventricle}, wall motion are normal {Normal ventricular wall motion}, aortic valve leaflets {Structure of cusp of aortic valve}, mildly thickened {Increased thickness}, aortic stenosis {Aortic valve stenosis}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are
mildly thickened {Thickened mitral leaflet}, mitral regurgitation {Mitral valve regurgitation}, pericardial effusion {Pericardial effusion}, biventricular {Cardiac ventricular structure}, thoracic aorta {Thoracic aorta structure}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, K {Blood potassium measurement}, Cl {Chloride measurement, blood}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
He underwent routine preoperative testing and evaluation.
Carotid ultrasound revealed bilateral carotid artery stenosis,
right > left. The vascular surgery service was consulted. Given
that he is asypmtomatic, recommendation is to follow up with Dr.
___ as an outpatient for further evaluation. He remained
hemodynamically stable and was taken to the operating room on
___. He underwent coronary artery bypass grafting x 3.
Please see operative note for full details. He tolerated the
procedure well and was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. Beta blocker was initiated and he was diuresed toward
his preoperative weight. His chest tubes were discontinued on
POD#1 and his epicardial pacing wires were discontinued on
POD#3. He had a +UTI and was started on Bactrim. He was started
on Kefzol for sternal drainage which resolved by the time
discharge and kefzol was stopped. He remained hemodynamically
stable and was transferred to the telemetry floor for further
recovery. He was evaluated by the physical therapy service for
assistance with strength and mobility and rehab was recommended.
By the time of discharge on POD #8 he was ambulating with
supervision, the sternal wound was healing without redness or
drainage, and pain was controlled with oral analgesics. He was
discharged to ___ Rehab in good condition with appropriate
follow up instructions.
###RESPONSE: evaluation {Evaluation procedure}, Carotid ultrasound {Ultrasonography of carotid artery}, carotid artery stenosis {Carotid artery stenosis}, right {Structure of right carotid artery}, left {Structure of left carotid artery}, asypmtomatic {Asymptomatic}, evaluation {Evaluation procedure}, hemodynamically stable {Hemodynamically stable}, coronary artery bypass grafting {Coronary artery bypass grafting}, stable
condition {Patient's condition stable}, neurologically intact {Normal nervous system function}, extubated {Removal of endotracheal tube}, vasopressor
support {Vasopressor therapy}, diuresed {Diuretic therapy}, epicardial pacing {Insertion of epicardial electrode for temporary cardiac pacing}, UTI {Urinary tract infectious disease}, sternal {Structure of sternal region}, drainage {Wound discharge}, hemodynamically
stable {Hemodynamically stable}, ambulating {Fully mobile}, supervision {Supervision}, sternal {Structure of sternal region}, wound was healing {Wound healing well}, redness {Redness of skin over lesion}, drainage {Discharge}, pain was controlled with oral analgesics {Demonstrates adequate pain control} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID
2. Simvastatin 80 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Diazepam 5 mg PO PRN nausea
5. Lisinopril 5 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Glargine 38 Units Dinner
8. fluocinolone acetonide oil 0.01 % otic DAILY
9. Omeprazole 40 mg PO DAILY
10. Propranolol LA 60 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. TraZODone 100 mg PO QHS:PRN insomnia
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Aspirin EC 81 mg PO DAILY
3. ClonazePAM 1 mg PO BID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth twice a day Disp #*65
Tablet Refills:*0
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Glargine 38 Units Dinner
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. Simvastatin 80 mg PO DAILY
9. TraZODone 100 mg PO QHS:PRN insomnia
10. BuPROPion (Sustained Release) 150 mg PO BID
11. Docusate Sodium 100 mg PO BID
12. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezes
14. Metoprolol Tartrate 25 mg PO BID
15. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth very 6 hours Disp #*65
Tablet Refills:*0
16. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
17. Furosemide 20 mg PO BID Duration: 5 Days
18. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
19. fluocinolone acetonide oil 0.01 % otic DAILY
20. Atorvastatin 80 mg PO QPM
21. Diazepam 5 mg PO PRN nausea
RX *diazepam 5 mg 1 tablet by mouth prn Disp #*25 Tablet
Refills:*0
22. Outpatient Lab Work
plaese check BUN/Creat on ___ and if greater than 1.3, please
continue to follow until off lasix and bactrim and returns to
baseline of 1.0
###RESPONSE: lasix {Diuretic therapy} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: NSTEMI
Secondary:
IDDM
HTN
Hyperlipidemia
GERD, s/p gastric ulcer ___ yrs ago
vertigo
chronic back pain
chronic headaches
deaf left ear
coronary artery disease s/p CABG ___
Past Surgical History: prostatectomy ___
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Oxycodone
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace
###RESPONSE: NSTEMI {Acute non-ST segment elevation myocardial infarction}, IDDM {Diabetes mellitus type 1}, HTN {Hypertensive disorder, systemic arterial}, Hyperlipidemia {Hyperlipidemia}, GERD {Gastroesophageal reflux disease}, gastric ulcer {Gastric ulcer}, vertigo {Vertigo}, chronic back pain {Chronic back pain}, chronic headaches {Chronic headache disorder}, deaf left ear {Deafness of left ear}, coronary artery disease {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, prostatectomy {Prostatectomy}, Alert {Mentally alert}, oriented x3 {Oriented to person, time and place}, Ambulating {Fully mobile}, steady gait {Gait normal}, Incisional {Surgical incision wound}, pain {Pain}, Incisions {Surgical incision wound}, Sternal {Structure of sternal region}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Leg Left {Structure of left lower leg}, healing well {Wound healing well}, erythema {Erythema}, drainage {Discharge}, Edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
###RESPONSE: incisions {Surgical incision wound}, redness {Redness of skin over lesion}, drainage {Discharge}, incisions {Surgical incision wound} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
___
Attending: ___.
Chief Complaint:
s/p mechanical fall
Major Surgical or Invasive Procedure:
None
###RESPONSE: fall {Falls} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ PMHx CAD s/p CABG, 2 prior colon surgeries, presenting as
transfer from ___ for trauma eval for R ___ rib
fractures due to mechanical fall. Patient reports trying to get
into his walker at his ___ this evening, when he tripped and
fell onto his right side. Denies LOC or headstrike. He sustained
a laceration to his R forearm and was sent to an OSH. head CT
head, torso, abdomen, CXR and x-ray R hand, found to have
non-displaced fractures of ___ to 9th ribs on right.
Upon evaluation in the ED, patient appears comfortable and NAD.
He is breathing well on room air, although his breaths still
appear to be shallow. He demonstrates significant pain along his
right flank.
###RESPONSE: CAD {Coronary arteriosclerosis}, CABG {Coronary artery bypass grafting}, colon {Colon structure}, surgeries {Surgical procedure}, trauma {Traumatic injury}, eval {Evaluation procedure}, rib
fractures {Fracture of multiple ribs}, fall {Falls}, walker {Uses zimmer frame}, fell {Falls}, right side {Structure of right half of body}, LOC {Loss of consciousness}, headstrike {Injury of head}, laceration {Laceration}, R forearm {Structure of right forearm}, head {Head structure}, CT
head {Computed tomography of head}, torso {Computed tomography of chest}, abdomen {Computed tomography of abdomen}, CXR {Plain chest X-ray}, x-ray R hand {Plain X-ray of right hand}, non-displaced fractures {Undisplaced fracture}, 9th ribs {Bone structure of ninth rib}, evaluation {Evaluation procedure}, comfortable {Comfortable appearance}, NAD {No abnormality detected}, breathing well on room air {Breathing room air}, shallow {Shallow breathing}, pain along his
right flank {Right flank pain} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
PMHx: CHF, CODP, CKD, anemia
###RESPONSE: CHF {Congestive heart failure}, CODP {Chronic obstructive lung disease}, CKD {Chronic kidney disease}, anemia {Anemia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non-contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
Admission
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:|
R ribs TTP along mid-axillary line, most prominent at rib 9. No
flail chest, no ecchymosis. Lungs clear anteriorly, pt refuses
to sit up for posterior exam. Head NCAT. R forearm with ~3 x 4
cm area of denuded skin.
Discharge Physical Exam:
VS: T: 97.4 PO BP: 113/68 L Sitting HR: 79 RR: 16 O2: 96% Ra
GEN: A+Ox3, NAD
HEENT: atraumatic, MMM
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXT: wwp, trace edema b/l UE. RUE abrasions with mepilex
###RESPONSE: Physical Exam {Physical examination procedure}, TTP {Tenderness}, mid-axillary line {Midaxillary line}, rib 9 {Bone structure of ninth rib}, flail chest {Flail chest}, ecchymosis {Ecchymosis}, Lungs {Examination of respiratory system}, NC {Normal head}, R forearm {Structure of right forearm}, denuded skin {Denuded skin}, VS {Vital signs finding}, T {Body temperature finding}, BP {Blood pressure finding}, HR {Finding of heart rate}, RR {Finding of rate of respiration}, O2 {Oxygen saturation measurement}, Ra {Breathing room air}, GEN {General examination of patient}, A+Ox3 {Oriented to person, time and place}, NAD {No abnormality detected}, atraumatic {No injuries apparent}, MMM {Moist oral mucosa}, CV {Cardiovascular physical examination}, RRR {Normal heart rate}, PULM {Examination of respiratory system}, CTA b/l {Normal breath sounds}, ABD {Examination of abdomen}, soft {Abdomen soft}, non-distended {Normal abdominal contour}, tender {Abdominal tenderness}, EXT {Examination of limb}, edema b/l UE {Edema of bilateral upper limbs}, RUE {Structure of right upper limb}, abrasions {Abrasion} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
IMAGING:
OSH Right Hand x-ray ___
Impression - No acute abnormality identified
OSH CT Chest w/ contrast ___
Impression - nondisplaced fractures of the lateral right ___
through 9th ribs
OSH CT abd/pelvis w/ contrast ___
Impression - No acute abnormality idenitified
OSH CT C-spine w/o contrast ___
Impression - there are degenerative disc and facet findings. No
acute abnormality identified
LABS:
___ 09:09PM GLUCOSE-102* UREA N-20 CREAT-1.2 SODIUM-138
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-15
___ 09:09PM CALCIUM-8.4 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 09:09PM WBC-6.7 RBC-3.03* HGB-11.1* HCT-33.0*
MCV-109* MCH-36.6* MCHC-33.6 RDW-16.3* RDWSD-65.7*
___ 09:09PM NEUTS-79.7* LYMPHS-7.6* MONOS-9.3 EOS-2.4
BASOS-0.4 IM ___ AbsNeut-5.34 AbsLymp-0.51* AbsMono-0.62
AbsEos-0.16 AbsBaso-0.03
___ 09:09PM PLT SMR-LOW* PLT COUNT-90*
___ 09:09PM ___ PTT-31.6 ___
###RESPONSE: IMAGING {Imaging}, x-ray {Radiographic imaging procedure}, No acute abnormality {No abnormality detected}, nondisplaced fractures {Undisplaced fracture}, 9th ribs {Bone structure of ninth rib}, No acute abnormality {No abnormality detected}, degenerative disc {Degeneration of intervertebral disc}, facet {Osteoarthritis of spinal facet joint}, No
acute abnormality {No abnormality detected}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, CALCIUM {Blood calcium measurement}, PHOSPHATE {Phosphate, total measurement}, MAGNESIUM {Blood magnesium measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, RDWSD {Red cell distribution width determination}, NEUTS {Neutrophil count}, LYMPHS {Lymphocyte count}, MONOS {Monocyte count}, EOS {Eosinophil count}, BASOS {Basophil count}, PLT {Platelet count}, PLT COUNT {Platelet count}, PTT {Partial thromboplastin time, activated} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
Mr. ___ is a ___ who presented as transfer from ___
for trauma evaluation for right ___ rib fractures s/p
mechanical fall. The patient was admitted to the trauma surgery
service for respiratory monitoring and pulmonary toilet. Pain
was managed with acetaminophen and tramadol.
The patient was alert and oriented throughout hospitalization.
The patient remained stable from a cardiovascular and pulmonary
standpoint. Vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient tolerated a
regular diet. The patient's fever curves were closely watched
for signs of infection, of which there were none. The patient's
blood counts were closely watched for signs of bleeding, of
which there were none. The patient received subcutaneous heparin
and ___ dyne boots were used during this stay and was
encouraged to get up and ambulate as early as possible.
The patient worked with Physical Therapy and ___ recommended
discharge to home with home physical therapy. At the time of
discharge, the patient was doing well, afebrile and
hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
###RESPONSE: trauma {Traumatic injury}, evaluation {Evaluation procedure}, right {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, fall {Falls}, respiratory monitoring {Monitoring of respiration}, pulmonary toilet {Airway toilet}, Pain {Pain}, alert {Mentally alert}, oriented {Orientated}, stable {Patient's condition stable}, Vital signs were routinely monitored {Monitoring of blood pressure, temperature, pulse rate and respiratory rate}, pulmonary
toilet {Airway toilet}, ambulation {Ambulation training}, incentive spirometry {Incentive spirometry}, tolerated a
regular diet {Tolerating normal diet}, fever {Fever}, watched
for signs of infection {Monitoring for signs and symptoms of infection}, blood counts {Cell count}, signs {Sign}, bleeding {Bleeding}, subcutaneous heparin {Subcutaneous injection of heparin}, ambulate {Ambulation training}, Physical Therapy {Physical therapy procedure}, physical therapy {Physical therapy procedure}, afebrile {Temperature normal}, hemodynamically stable {Hemodynamically stable}, tolerating a diet {Tolerating diet}, ambulating {Fully mobile}, voiding without assistance {Continence independent}, pain was well
controlled {Demonstrates adequate pain control} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Tylenol
Diltiazem ER 120mg
Flovent 220mcg HFA BID
Folic acid 1mg
Furosemide 20mg
Guaifensin 10cc q4 prn cough
Ipratropium-albuterol q4 prn
Loperamide 2mg TID prn
Methotrexate 2.5mg (7.5mg weekly on ___
Omeprazole 20mg daily
Pro-air HFA 90mcg inhaler
Procrit 40,000 ___
Spiriva 18mcg
Trazodone 50mg qhs
Vitamin B12 1000mcg daily
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Lidocaine 5% Patch 1 PTCH TD DAILY
apply patch and leave on for 12 hours, and then remove and leave
off for 12 hours
RX *lidocaine 5 % Apply one patch to area of rib pain Daily Disp
#*7 Patch Refills:*0
4. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*15 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg PO DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Epoetin ___ ___ Units SC WEEKLY
8. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheezing
12. LOPERamide 2 mg PO TID:PRN diarrhea
13. Methotrexate 7.5 mg PO 1X/WEEK (___)
14. Omeprazole 20 mg PO DAILY
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
16. Tiotropium Bromide 1 CAP IH DAILY
17. TraZODone 50 mg PO QHS
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Right ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
###RESPONSE: Right {Bone structure of right rib}, rib fractures {Fracture of rib}, Mental Status {Neurological mental status determination}, Clear {Normal state of mind}, Level of Consciousness {Assessment of consciousness level}, Alert {Mentally alert}, interactive {Does communicate}, Activity Status {Physical functional dependency}, Ambulatory - Independent {Independent walking} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
Dear Mr. ___,
You were transferred to ___ in
___ with multiple right-sided rib fractures after a fall.
You were admitted to the Trauma Surgery Service for pain control
and to monitor your breathing. While in the hospital, you worked
with Physical Therapy and it is recommended that you have
Physical Therapy services come to your home to help you regain
your strength. You are now ready to be discharged home. Please
note the following discharge instructions:
* Your injury caused right-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
###RESPONSE: right-sided {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, fall {Falls}, pain control {Pain control}, monitor {Monitoring for signs and symptoms of infection}, injury {Traumatic injury}, right-sided {Bone structure of right rib}, rib fractures {Fracture of multiple ribs}, severe pain {Severe pain}, shallow breaths {Shallow breathing}, pain {Pain}, pain medication {Administration of analgesic}, pain {Pain}, able to take deep breaths {Able to take deep breaths}, pain medication {Administration of analgesic}, Pneumonia {Pneumonia}, rib fractures {Fracture of multiple ribs}, decrease your risk {Preventive procedure}, use your incentive spirometer {Incentive spirometry}, airways {Airway structure}, lungs {Lung structure}, lungs {Lung structure}, chest {Thoracic structure}, rib cage {Thoracic cage structure}, coughing and
deep breathing {Deep breathing and coughing exercises}, relief {Pain relief}, ice packs {Application of ice}, heating pads {Heat therapy}, pain {Pain}, constipation {Constipation}, take a stool softener {Administration of laxative}, increase your fluid {Fluid intake encouragement}, fiber intake {High fiber diet education}, Do NOT smoke {Smoking cessation education}, controlling pain {Pain control}, shortness of breath {Dyspnea}, increased pain {Increased pain}, crackling {Respiratory crackles}, ribs {Bone structure of rib}, crepitus {Bone crepitus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Morphine / Aspirin / Methocarbamol / Meperidine / Hydrocodone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
###RESPONSE: Morphine {Allergy to morphine}, Aspirin {Allergy to aspirin}, Dyspnea {Dyspnea} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
___ with PMH of CHF, AAA, and chronic back pain presenting from
Rehab with confusion and disorientation, found to have a T=101,
SaO2=88%. She was sent to the emergency room for further
evaluation. In the emergency room she was somnolent, but
arousable, and was confused and disoriented. She was transiently
hypotensive and received ___ of IVF. CXR was consistent with
pneumonia and she was given Vancomycin, Levofloxacin, and Zosyn.
She was then transferred to the MICU for further management.
###RESPONSE: CHF {Congestive heart failure}, AAA {Abdominal aortic aneurysm}, chronic back pain {Chronic back pain}, confusion {Clouded consciousness}, disorientation {Disorientated}, SaO2 {Finding of oxygen saturation}, emergency {Emergency treatment management}, evaluation {Evaluation procedure}, emergency {Emergency treatment management}, confused {Clouded consciousness}, disoriented {Disorientated}, hypotensive {Low blood pressure}, IVF {Administration of intravenous fluids}, CXR {Plain chest X-ray}, pneumonia {Pneumonia}, Vancomycin {Antibiotic therapy}, Levofloxacin {Antibiotic therapy}, transferred to the MICU {Patient transfer to intensive care unit} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
CHF: EF unknown
AAA
Back Pain
GERD
Depression
###RESPONSE: CHF {Congestive heart failure}, AAA {Abdominal aortic aneurysm}, Back Pain {Backache}, GERD {Gastroesophageal reflux disease}, Depression {Depressive disorder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Family History:
Non-contributory
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
T=95.7 HR=71 BP=99/39 RR=22 SpO2=92%
General: NAD
HEENT: Anicteric
CV: RR, ___ systolic murmur
Pulm: crackles on R>L, dullness at L base
Abd: soft, NTND, positive bowel sounds
Ext: no edema
###RESPONSE: HR {Finding of heart rate}, BP {Blood pressure finding}, RR {Finding of rate of respiration}, SpO2 {Finding of oxygen saturation}, General {General examination of patient}, NAD {No abnormality detected}, HEENT {Physical examination procedure}, Anicteric {White sclera}, CV {Cardiovascular physical examination}, RR {Finding of rate of respiration}, murmur {Murmur}, Pulm {Examination of respiratory system}, crackles {Respiratory crackles}, dullness {Chest dull to percussion}, L base {Structure of base of left lung}, Abd {Examination of abdomen}, soft {Abdomen soft}, ND {Swollen abdomen}, Ext {Examination of limb}, edema {Edema} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 06:06PM TYPE-ART RATES-/28 PO2-98 PCO2-53* PH-7.32*
TOTAL CO2-29 BASE XS-0 INTUBATED-NOT INTUBA
___ 02:07PM LACTATE-1.2
___ 01:58PM GLUCOSE-106* UREA N-22* CREAT-1.4* SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
___ 01:58PM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-179* TOT
BILI-0.6
___ 01:58PM LIPASE-11
___ 01:58PM proBNP-___*
___ 01:58PM WBC-19.4*# RBC-3.26*# HGB-8.8*# HCT-28.9*#
MCV-89 MCH-26.9* MCHC-30.4* RDW-16.5*
___ 01:58PM ___ PTT-27.8 ___
___ 07:10PM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
6.8 3.55* 9.6* 30.4* 86 27.0 31.6 17.3* 443*
Glucose UreaN Creat Na K Cl HCO3 AnGap
112* 14 1.2* 142 3.6 104 31 11
___ 15:27 ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The right atrial pressure is indeterminate.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened. There is mild aortic
valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
___ CXR
In comparison with the study of ___, there is again
enlargement
of the cardiac silhouette with evidence of some pulmonary
vascular congestion. Areas of increased opacification are seen
at both bases with apparent silhouetting the hemidiaphragm. This
most likely represents combination of atelectasis and effusion,
though superimposed pneumonia be definitely excluded.
###RESPONSE: PO2 {Oxygen measurement, partial pressure, arterial}, PCO2 {Measurement of arterial partial pressure of carbon dioxide}, PH {pH measurement}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, BASE XS {Delta base, blood}, INTUBATED {Intubation}, GLUCOSE {Glucose measurement, blood}, UREA N {Blood urea nitrogen measurement}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, ALT {Alanine aminotransferase measurement}, AST {Aspartate aminotransferase measurement}, PHOS {Phosphate, total measurement}, TOT
BILI {Bilirubin, total measurement}, LIPASE {Triacylglycerol lipase measurement}, proBNP {N-terminal pro-brain natriuretic peptide measurement}, WBC {White blood cell count}, RBC {Red blood cell count}, HGB {Measurement of total hemoglobin concentration}, HCT {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, PTT {Partial thromboplastin time, activated}, WBC {White blood cell count}, RBC {Red blood cell count}, Hct {Hematocrit determination}, MCV {Erythrocyte mean corpuscular volume determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement}, ECHO {Echocardiography}, left atrium is elongated {Left atrial enlargement}, atrial septal defect {Atrial septal defect}, color Doppler {Color Doppler ultrasound}, right atrial {Right atrial structure}, mild symmetric left ventricular hypertrophy {Mild left ventricular hypertrophy}, normal
cavity size {Normal size}, regional/global systolic function {Normal left ventricular systolic function and wall motion}, ventricular septal defect {Ventricular septal defect}, Right ventricular chamber {Right cardiac ventricular structure}, size {Normal size}, wall motion are normal {Normal ventricular wall motion}, aorta at
the sinus {Structure of sinus of Valsalva}, ascending {Ascending aorta structure}, arch {Aortic arch structure}, normal {No abnormality detected}, aortic
valve leaflets {Structure of cardiac valve leaflet}, mildly thickened {Increased thickness}, mild aortic
valve stenosis {Mild stenosis of aortic valve}, aortic regurgitation {Aortic valve regurgitation}, mitral valve leaflets are mildly thickened {Thickened mitral leaflet}, mitral valve prolapse {Mitral valve prolapse}, Trivial mitral regurgitation {Mild mitral valve regurgitation}, tricuspid valve leaflets are mildly thickened {Tricuspid leaflet thickened}, moderate pulmonary artery systolic hypertension {Moderate pulmonary hypertension}, pericardial effusion {Pericardial effusion}, CXR {Plain chest X-ray}, study {Evaluation procedure}, enlargement {Enlargement}, cardiac {Heart structure}, pulmonary
vascular congestion {Pulmonary congestion}, opacification {Abnormally opaque structure}, bases {Structure of base of lung}, atelectasis {Atelectasis}, effusion {Pleural effusion}, pneumonia {Pneumonia} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Brief Hospital Course:
___ with PMH of CHF, depression, AAA, GERD presenting with
altered mental status and hypotension, found to have sepsis
likely due to a multi-lobar pneumonia admitted to the ICU for
two days and transferred to medical floor on ___. She did
not require tracheal intubation in the ICU.
1. Pneumonia: Urine legionella negative, blood cultures (NGTD
from ___, viral culture negative. Patient improved on
Vanc/Zosyn with steady improvement in her oxygen saturation to
normal on RA at the time of discharge. She received an 8day
course of antibiotics, then they were discontinued. Oxygen was
given and eventually weaned off. Asnoted above, she did not
require tracheal intubation in the ICU.
2. Dyspnea: Likely multifactorial due to pneumonia, and a
component of diastolic congestive heart failure with volume
resuscitation in the ER. Initial BNP elevated, and blood
tests/EKG did not reveal suggestive myocardial injury. Patient
responded well to intermittent doses of Lasix 10mg IV.
3. Hypertension: Pt had episodes of hypotension at presentation;
on the general medicine floor she remained intermitently
hypertensive to SBP=180 despite Labetalol 200mg BID, which is
her home regiment. Elevated values tended to be right before
next dose of medicine is given; otherwise relatively
well-controlled. on discharge =150s/70s
4. Chronic diastolic CHF: TTE obtained this hospitalization
showed EF>55%, no echocardiographic evidence of diastolic
dysfunction, only mild LVH on TTE. She was continued on
Labetalol as above for BP and rate control.
5. Anemia: Hct improved slowly to 31 at the time of discharge,
MCV=89, baseline unknown. Given MCV, likely due to anemia of
chronic disease, eval studies were consistent with this.
6. Lumbar disc disease - s/p lumbar surgery. Back pain was
slightly worse in hospital and so her Oxycontin to increased to
40mg BID on ___ with good effect. Not requireing breakthrough
pain. Valium was decreased to 2mg BID, and she's being
discharged on 2mg once daily prn anxiety. She has not displayed
high levels of anxiety, though the valium had been given to her
prior to hospitalization more to help any spasm component of her
back pain.
###RESPONSE: CHF {Congestive heart failure}, depression {Depressive disorder}, AAA {Abdominal aortic aneurysm}, GERD {Gastroesophageal reflux disease}, altered mental status {Altered mental status}, hypotension {Low blood pressure}, sepsis {Sepsis}, lobar pneumonia {Lobar pneumonia}, ICU {Patient transfer to intensive care unit}, tracheal intubation {Insertion of endotracheal tube}, ICU {Patient transfer to intensive care unit}, Pneumonia {Pneumonia}, Urine {Urinalysis}, legionella {Legionella infection}, blood cultures {Blood culture}, viral culture {Viral culture}, improved {Patient's condition improved}, Vanc {Antibiotic therapy}, improvement {Patient's condition improved}, oxygen saturation to
normal {Oxygen saturation within reference range}, antibiotics {Antibiotic therapy}, discontinued {Recommendation to stop drug treatment}, tracheal intubation {Insertion of endotracheal tube}, ICU {Patient transfer to intensive care unit}, Dyspnea {Dyspnea}, pneumonia {Pneumonia}, diastolic congestive heart failure {Heart failure with normal ejection fraction}, volume
resuscitation {Oxygen therapy}, BNP {Brain natriuretic peptide measurement}, blood
tests {Blood test}, EKG {Electrocardiographic procedure}, injury {Traumatic or non-traumatic injury}, responded well {Good therapeutic response}, Lasix {Diuretic therapy}, Hypertension {Hypertensive disorder, systemic arterial}, hypotension {Low blood pressure}, hypertensive {Finding of increased blood pressure}, SBP {Increased systolic arterial pressure}, regiment {Therapeutic regimen}, Elevated {Finding of increased blood pressure}, well-controlled {Disease condition determination, well controlled}, Chronic diastolic CHF {Chronic diastolic heart failure}, TTE {Transthoracic echocardiography}, echocardiographic {Echocardiography}, diastolic
dysfunction {Diastolic dysfunction}, mild LVH {Mild left ventricular hypertrophy}, TTE {Transthoracic echocardiography}, Anemia {Anemia}, improved {Patient's condition improved}, MCV {Erythrocyte mean corpuscular volume determination}, baseline {Baseline state}, MCV {Erythrocyte mean corpuscular volume determination}, anemia of
chronic disease {Anemia of chronic disorder}, eval {Evaluation procedure}, studies {Evaluation procedure}, Lumbar disc disease {Disorder of lumbar disc}, Back pain {Backache}, worse {Increased pain}, good effect {Good therapeutic response}, breakthrough
pain {Breakthrough pain}, anxiety {Anxiety}, levels of anxiety {Level of anxiety}, spasm {Spasm}, back pain {Backache} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Medications on Admission:
Lidoderm patch
Levothyroxine 25mcg po qday
prilosec 20mg po qday
cymbalta 60mg po qday
colace 100mg po bid
labetalol 200mg po bid
xoycontin 30mg po bid
senna 1 tablet po bid
diazepam 5mg po q6h prn anxiety
oxycodone 10mg po q6 prn pain
mvi daily
lyrica 50mg po qday
robitussin prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for chronic back pain.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze, shortness of breath.
10. Diazepam 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
11. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
Congestive Heart Failure (diastolic)
Low Back Pain
Discharge Condition:
Improved
###RESPONSE: Pneumonia {Pneumonia}, Congestive Heart Failure {Congestive heart failure}, diastolic {Diastolic heart failure}, Low Back Pain {Low back pain}, Improved {Patient's condition improved} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Discharge Instructions:
You were admitted with pneumonia and sepsis and treated for this
in the ICU and hospital floor with antibiotics and have
completed this course. You had an ultrasound of the heart which
was normal. Your back pain medication was adjusted for increased
pain. If you have fever, cough, shortness of breath, chest pain
or worsening back pain, please have this evaluated by your
doctor.
###RESPONSE: pneumonia {Pneumonia}, sepsis {Sepsis}, ICU {Patient transfer to intensive care unit}, antibiotics {Antibiotic therapy}, ultrasound {Ultrasonography}, heart {Heart structure}, normal {No abnormality detected}, pain medication {Administration of analgesic}, adjusted {Drug dosage altered}, increased
pain {Increased pain}, fever {Fever}, cough {Cough}, shortness of breath {Dyspnea}, chest pain {Chest pain}, worsening {Increased pain}, back pain {Backache}, evaluated {Evaluation procedure} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Followup Instructions:
___
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT:
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
hematuria, urinary retention
Major Surgical or Invasive Procedure:
___ Dr. ___, bladder biopsy
###RESPONSE: Bactrim {Allergy to sulfamethoxazole and/or trimethoprim}, hematuria {Blood in urine}, urinary retention {Retention of urine}, bladder biopsy {Biopsy of bladder} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: History of Present Illness:
Mr. ___ is a ___ with a history of BPH. He states that he saw
a urologist more than ___ years ago and was started on terazosin.
He also underwent urodynamics and cystoscopy around ___ years
ago and was told that he will likely need an operation.
Yesterday, he presented to the ED in urinary retention following
4 days of weak stream. A foley was placed and he was found to
have a UTI. He was discharged with a 7d course of cipro. Last
night he noticed blood in his catheter which got progressibly
darker in appearanced. He returned to the ED this morning. His
catheter was changed to a 3 way foley, he was hand irrigated
with return of clots and he was placed on CBI. A few hours
later his drainage became bloody again and he was hand irrigated
with further return of clots.
###RESPONSE: BPH {Benign prostatic hyperplasia}, urodynamics {Urodynamic studies}, cystoscopy {Transurethral cystoscopy}, operation {Surgical procedure}, urinary retention {Retention of urine}, weak stream {Poor stream of urine}, foley was placed {Introduction of urinary catheter}, UTI {Urinary tract infectious disease}, blood {Blood in urine}, catheter was changed {Change of urethral catheter}, foley {Catheterization of urinary bladder}, hand irrigated {Manual bladder washout through catheter}, clots {Blood clot}, CBI {Monitoring of continuous bladder irrigation}, s hand irrigated {Manual bladder washout through catheter}, clots {Blood clot} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Past Medical History:
Diabetes type 2, complicated by retinopathy
h/o syphilis
Angioedema
Glaucoma
BPH
spinal stenosis
s/p laminectomy
Paget's disease
s/p shoulder surgery
gout
lichen planus
###RESPONSE: Diabetes type 2 {Diabetes mellitus type 2}, retinopathy {Retinal disorder}, syphilis {Syphilis}, Angioedema {Angioedema}, Glaucoma {Glaucoma}, BPH {Benign prostatic hyperplasia}, spinal stenosis {Spinal stenosis}, laminectomy {Excision of lamina of vertebra}, Paget's disease {Osteitis deformans}, shoulder {Structure of left shoulder region}, surgery {Surgical procedure}, gout {Inflammatory disorder due to increased blood urate level}, lichen planus {Lichen planus} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Social History:
###RESPONSE: EMPTY: No SNOMED annotations found in this fragment |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Physical Exam:
nad
Abd soft, nt/nd
Foley with clear yellow urine
###RESPONSE: nad {No abnormality detected}, soft {Abdomen soft}, Foley {Urinary catheter in situ}, clear yellow urine {Urine looks clear} |
###HUMAN: Your task is to process the following fragment of a medical note, retrieving and listing all SNOMED annotations found inside. You will return an "EMPTY: No SNOMED annotations found in this fragment" if there are none. For any that you find, you will return a list of: "text {annotation}", where 'text' is the part of the text that corresponds to the annotation, and 'annotation' is the corresponding SNOMED-CT annotation. This is the text to analyze:
###TEXT: Pertinent Results:
___ 08:30PM HCT-37.7*
___ 11:00AM GLUCOSE-238* UREA N-19 CREAT-1.1 SODIUM-142
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
___ 3:15 pm URINE Site: CLEAN CATCH
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- ___ I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 07:04PM BLOOD WBC-13.4* RBC-3.76* Hgb-11.2* Hct-34.0*
MCV-90 MCH-29.7 MCHC-32.8 RDW-13.7 Plt ___
___ 07:18AM BLOOD WBC-12.1* RBC-3.62* Hgb-10.6* Hct-32.4*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.8 Plt ___
___ 07:18AM BLOOD Glucose-122* UreaN-14 Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-29 AnGap-12
###RESPONSE: HCT {Hematocrit determination}, GLUCOSE {Glucose measurement, blood}, CREAT {Creatinine measurement}, SODIUM {Sodium measurement}, POTASSIUM {Potassium measurement}, CHLORIDE {Chloride measurement, blood}, TOTAL CO2 {Blood total carbon dioxide (calculated)}, ANION GAP {Anion gap measurement}, URINE {Urine culture}, CATCH {Urine specimen collection, clean catch}, URINE CULTURE {Urine culture}, sensitivity {Antimicrobial susceptibility test}, SENSITIVITIES {Antimicrobial susceptibility test}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, WBC {White blood cell count}, RBC {Red blood cell count}, Hgb {Measurement of total hemoglobin concentration}, Hct {Hematocrit determination}, MCH {Mean corpuscular hemoglobin determination}, MCHC {Mean corpuscular hemoglobin concentration determination}, RDW {Red cell distribution width determination}, Glucose {Glucose measurement, blood}, UreaN {Blood urea nitrogen measurement}, Creat {Creatinine measurement}, Na {Blood sodium measurement}, Cl {Chloride measurement, blood}, HCO3 {Blood bicarbonate measurement}, AnGap {Anion gap measurement} |
Subsets and Splits